21 - Aural sx

common surgical ear conditions

chronic otitis externa

otitis media

feline inflammatory polyps

aural hematoma

inner/external tumors

pinnal trauma

otitis externa

may lead to irreversible changes → hyperplasia, ossification

most likely to have concurrent otitis media

allergies, immune-mediated, systemic dz, physcial attributes

indications for sx

medical managemetn failure

severe stenosis → after neoplasia R/O

imaging for surgical planning

CT preferred → canal and bulla eval

radiographs less sensitive → possibly have normal-looking bullae

surgical options

lateral ear canal resection

poor choice for chronic otitis externa

not helpful for otitis media/canal stenosis

vertical ear canal ablation

not helpful for otitis media/canal stenosis

less painful that LECR

good for tumors confined to vertical ear canal

may contract facial nerve palsy (rare)

LECR/VECA complications

inadequate drainage

continued otitis externa

clinical signs not relieved in dogs with underlying dermatologic disease

continued otitis externa if performed with concurrent untreated otitis media

TECA-BO

total ear canal ablation + Bulla Osteotomy

most common sx of external/middle ear

can remove external/middle ear tumors → image to be sure

salvage procedure

many potential complications

improved QOL for chronic otitis

hearing impaction

usually already severely impaired by otitis meda/externa pathophys changes

TECA-BO has minimal additional impact

some transmission of vibration through skull possible

pre-op plan

control ear infection as well as possible

 R/O Neoplasia → otoscopic exam, CT, MRI

informed consent → complications can be serious

complications

residual inner ear infection → additional costs

facial nerve injury (permanent or temporary)

draining tracts → incomplete removal to tissue → months to years after procedure

pinna necrosis

horner’s syndrome

pain on opening mouth → usually resolves in 2-4 weeks

vestibular syndrome → will usually resolve

facial nerve paralysis

diminished palpebral reflex

widened palpebral fissure

drooping ear/lip

excessive drooling

blepharospasm

elevation/wrinkling of lip

caudal displacement of labial commisure

technique

  1. incise around external canal orifice

  2. T-shape incision extended down canal

  3. cartilage at distal canal cut

  4. soft tissues circumferentially dissected down to eardrum

facial nerve → at junction between annular and auricular cartilage → cdvt aspect of canal; may be adhered to canal

stay as close to cartilage as possible to avoid other important structures → maxiallyar a, external carotid

  1. canal cut and removed at ear drum

  2. meatus widened to remove part of laterall bulla

    cats have septated bulla

  1. collect sample for C/S

  2. gentle curettage and debride until only bone remains → can result in vestibular/Horner’s signs

  3. flush/culture

  4. can place wound soaker catheter for post-op anesthetics

  5. closed-ended drain placed

post-op

analgesia, sedatives

cold pack for swelling

soft food for 4-6 weeks

abx based on culture → 6-8 wks

E collar

monitor for neuro signs → may need artificial tears/lubricant

feline inflammatory polyps

nasopharyngeal

extend into pharyngeal cavity

signs of upper airway obstruction → stertor, nasal discharge, gagging, dysphagia, dyspnea

less likely to recur than aural ones

aural

from middle ear or auditory tubes (young cats)

present like otitis externa

tx: traction at base of polyp

ventral bulla osteotomy

allows increased exposure of tympanic cavity

performed alone or with LECR

good for access to epithelial lining of bulla → better than LBO

allows for bilateral procedure without reposition of animal

procedure

  • extend neck to palpate bulla

  • incise over bulla → at bifurcation of lingual/facial vv

  • blunt dissect through musculature

  • expose ventral wall → caution of lingual v/a + hypoglossal nerve (medial), lymph node, facial v/n

  • use cuck/drill to enter bulla, extend with rongeurs

  • open septum to access/debride mesotympanum → avoid injury to promontory

  • caution dorsal in dogs

  • caution lateral in cats

Horner’s syndrome

damage to sympathetic tract to eye

clinical signs

constricted pupil → miosis

elevated third eyelid

enopthalmos → sunken eye

ptosis → droopy eyelids

aural hematoma

excessive head shaking/scratching/rubbing → vessel rupture

hematoma w/in cartilage or between cartilage & skin

chronic: granulation tissue → boxer/cauliflower ear

treat underlying cause!

conservative treatment\

if concurrent otitis externa present → treat simultaneously

benign neglect

can eventually resolve w/o intervention → limit head movement

more likely to form caulflower ear

aseptic drainage

clip, prep, drain

passive: teat cannulas, penrose, fenestrated tubing

active: butterfly catheter + vacutainer, JP drain

indications for sx

persistent swelling

recurrence

prevention of fibrosis/deformity

surgical treatment

allows for continued surgical drainage over period of time

s-shaped incision over/into hematoma

remove fibrin clot

irrigate cavity

stent sutures for skin & cartilage

place parallel to long axis of pinna → don’t disrupt blood flow

remove in 2-3 weeks

laser to remove fenestrations

ear/head wrap + e collar

pinnectomy

indications

neoplasia

wounds/trauma

technique

can cut cartilage with may scissors → greater control

appose skin over cut edges

tumors/wx at base of pinna may require lateral wall resection → appose skin to cear canal mucosa

ensure external canal orifice maintained

ear lacerations

linear skin surface → secondary intention or simple interrupted sutures

place sutures through skin and cartilage at center of flap → eliminate dead space

if full-thickness → can use vertical mattress on one side, simple interrupted on other side